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Osteoporosis

About

What is covered

This pathway covers NICE guidance on osteoporosis in adults (18 years and older), including assessing the risk of fragility fracture and drug treatment for the primary and secondary prevention of osteoporotic fragility fractures.
Osteoporosis is a disease characterised by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture.
Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture (equivalent to a fall from a standing height or less), known as low-level (or 'low energy') trauma.
Reduced bone density is a major risk factor for fragility fractures. Other factors that may affect risk of fragility fractures include the use of oral or systemic glucocorticoids, age, sex, previous fractures and family history of osteoporosis. Because of increased bone loss after the menopause in women, and age-related bone loss in both women and men, the prevalence of osteoporosis increases markedly with age. As the longevity of the population increases, so will the incidence of osteoporosis and fragility fracture.
Fragility fractures occur most commonly in the spine (vertebrae), hip (proximal femur), and wrist (distal radius). They may also occur in the arm (humerus), pelvis, ribs and other bones. Major osteoporotic fractures are defined as fractures associated with low bone mineral density (BMD) and includes clinical spine, forearm, hip or shoulder fractures.
Osteoporotic fragility fractures can cause substantial pain and severe disability, often leading to a reduced quality of life. Hip and vertebral fractures are associated with decreased life expectancy. Hip fracture nearly always requires hospitalisation and can be fatal or permanently disabling. There are a number of therapies and treatments available for the prevention of fragility fractures in people who are thought to be at risk, or to prevent further fractures in those who have already had one or more fragility fractures.
Identifying who will benefit from preventative treatment is imprecise. A number of risk assessment tools are available to predict fracture incidence over a period of time, and these may be used to aid decision-making. This pathway provides guidance on the selection and use of risk assessment tools in the care of people who may be at risk of fragility fractures.

Updates

Updates to this pathway

20 September 2016 Recommendation on bisphosphonate treatment from NICE guideline NG56 on multimorbidity added to primary prevention of osteoporotic fragility fractures in postmenopausal women and secondary prevention of osteoporotic fragility fractures in postmenopausal women.
2 September 2013 Information about independent clinical risk factors removed from the section on denosumab in secondary prevention of osteoporotic fragility fractures in postmenopausal women. The use of denosumab for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (recommendation 1.2 of NICE technology appraisal guidance 204) does not depend on independent clinical risk factors.
24 April 2013 Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for osteoporotic vertebral compression fractures (NICE technology appraisal guidance 279) added to treatment of vertebral compression fractures.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on assessing the risk of, preventing and treating osteoporotic fragility fractures in adults in an interactive flowchart.

What is covered

This pathway covers NICE guidance on osteoporosis in adults (18 years and older), including assessing the risk of fragility fracture and drug treatment for the primary and secondary prevention of osteoporotic fragility fractures.
Osteoporosis is a disease characterised by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture.
Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture (equivalent to a fall from a standing height or less), known as low-level (or 'low energy') trauma.
Reduced bone density is a major risk factor for fragility fractures. Other factors that may affect risk of fragility fractures include the use of oral or systemic glucocorticoids, age, sex, previous fractures and family history of osteoporosis. Because of increased bone loss after the menopause in women, and age-related bone loss in both women and men, the prevalence of osteoporosis increases markedly with age. As the longevity of the population increases, so will the incidence of osteoporosis and fragility fracture.
Fragility fractures occur most commonly in the spine (vertebrae), hip (proximal femur), and wrist (distal radius). They may also occur in the arm (humerus), pelvis, ribs and other bones. Major osteoporotic fractures are defined as fractures associated with low bone mineral density (BMD) and includes clinical spine, forearm, hip or shoulder fractures.
Osteoporotic fragility fractures can cause substantial pain and severe disability, often leading to a reduced quality of life. Hip and vertebral fractures are associated with decreased life expectancy. Hip fracture nearly always requires hospitalisation and can be fatal or permanently disabling. There are a number of therapies and treatments available for the prevention of fragility fractures in people who are thought to be at risk, or to prevent further fractures in those who have already had one or more fragility fractures.
Identifying who will benefit from preventative treatment is imprecise. A number of risk assessment tools are available to predict fracture incidence over a period of time, and these may be used to aid decision-making. This pathway provides guidance on the selection and use of risk assessment tools in the care of people who may be at risk of fragility fractures.

Updates

Updates to this pathway

20 September 2016 Recommendation on bisphosphonate treatment from NICE guideline NG56 on multimorbidity added to primary prevention of osteoporotic fragility fractures in postmenopausal women and secondary prevention of osteoporotic fragility fractures in postmenopausal women.
2 September 2013 Information about independent clinical risk factors removed from the section on denosumab in secondary prevention of osteoporotic fragility fractures in postmenopausal women. The use of denosumab for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (recommendation 1.2 of NICE technology appraisal guidance 204) does not depend on independent clinical risk factors.
24 April 2013 Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for osteoporotic vertebral compression fractures (NICE technology appraisal guidance 279) added to treatment of vertebral compression fractures.

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Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

bone mineral density
dual-energy X-ray absorptiometry
The level of risk at which an intervention is recommended. People whose risk is in the region from just below to just above the threshold may be reclassified if BMD is added to assessment. It was out of the scope of the osteoporosis: fragility fracture risk clinical guideline to recommend intervention thresholds. Healthcare professionals should follow local protocols or other national guidelines for advice on intervention thresholds.
standard deviations

Paths in this pathway

Pathway created: August 2012 Last updated: September 2016

© NICE 2016

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